CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Synagis (palivizumab) prior authorization request — coverage criteria and submission form

Form and criteria for requesting outpatient Synagis (palivizumab, CPT 90378) authorization for infants and young children through Highmark Blueshield NENY; directed to providers submitting authorization for medical benefit administration or pharmacy dispensing.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Synagis (palivizumab) prior authorization request — coverage criteria and submission form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the outpatient Synagis authorization form, attach required clinical documentation, and fax to 1-833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 90378Synagis procedure code referenced

5Max doses per RSV season

Fax 1-833-619-5745Form submission

<=12 mo; >12–<24 moAge bands captured

Coverage and Eligibility Criteria

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Initial/Eligibility Criteria (form-captured)

Coverage considerations captured on the form — selection of applicable high‑risk clinical categories and age bands.

Age categories: Current age <= 12 months OR current age >12 months to <24 months (checkboxes on form)

Form requires marking applicable age band and verifying eligibility/benefits

High-risk indications: Infant with preterm birth less than 29 weeks 0 days; Infant with preterm birth less than 32 weeks 0 days with chronic lung disease (CLD); Infant is profoundly immunocompromised during the RSV season; Infant is undergoing a cardiac transplant; Infant with Cystic Fibrosis (with evidence of CLD or nutritional compromise or severe disease); Infant with hemodynamically significant congenital heart disease; Infant with history of chronic lung disease of prematurity that continues to require medical support (e.g., supplemental oxygen, chronic corticosteroids, diuretic therapy); Infant born with congenital airway abnormalities; Infant born with a neuromuscular condition that compromises handling of respiratory secretions; Other (free-text)

Form collects indication-specific follow-up items (e.g., maximum % oxygen after birth, days of oxygen, medication for heart failure, weight/length <10th percentile, presence of pulmonary hypertension, prior hospitalizations, imaging findings).

The authorization form does not include a separate or explicit list of coverage exclusions. The document presents the clinical criteria and risk categories to be completed by the requester but contains no section titled or formatted as an exclusion list; therefore, no exclusions are specified on the form.

The form does not enumerate conditions that are expressly labeled as "not medically necessary." Instead, it collects specific clinical information and selectable high‑risk criteria (age bands, prematurity, chronic lung disease, congenital heart disease, immunocompromise, cystic fibrosis, airway/neuromuscular disorders, etc.) that the reviewer will use to determine medical necessity.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient Synagis (palivizumab). Use the Outpatient Medical Injectable Synagis Authorization Request Form to request prior authorization. Fax the completed form and all required documentation to Highmark at 1-833-619-5745.

Form title: Outpatient Medical Injectable Synagis Authorization Request Form (Medical Benefit Only)
Fax number for submission: 1-833-619-5745
Verify member eligibility and benefits through the health plan prior to submission

Step Therapy

Dose-count Step — Document Prior and Requested Doses

On the form, indicate the number of Synagis doses the infant has already received during the current RSV season and the number of doses being requested now. Note that the local RSV season maximum is 5 doses per season; ensure total doses (already received + requested) do not exceed this maximum.

Field: "Number of doses infant has already received during current RSV season (NICU and non-NICU doses)"
Field: "Number of doses requested this current RSV season"
Season maximum: Maximum of 5 doses within the local RSV season

Documentation Required

Required Documentation

Include all required clinical documentation with the completed form. Failure to submit the completed form and supporting documentation by fax to 1-833-619-5745 may result in denial or delay of authorization.

Required attachments: pertinent clinical records, referral, and prescription to dispensing pharmacy (if applicable)
Clinical data to include: date of birth (DOB), member UMI, gestational age at birth (weeks and days), birth weight, current age and weight, relevant ICD-10 diagnosis codes, documentation of number and dates of prior Synagis doses in the current RSV season
Specific clinical criteria/supporting information: evidence of prematurity (e.g., <29 weeks 0 days or <32 weeks 0 days with CLD), diagnosis of chronic lung disease of prematurity with current medical support, hemodynamically significant congenital heart disease (including medications for congestive heart failure, planned cardiac surgery, weight/length <10th percentile, pulmonary hypertension), profound immunocompromise, cystic fibrosis with severe disease or CLD, neuromuscular conditions compromising secretion clearance, oxygen/diuretic/corticosteroid requirements, and any prior hospitalizations or imaging supporting severity
Attach all pertinent clinical information and the referral/prescription to the dispensing pharmacy if applicable

Documentation Required

Submission Requirement — Fax Completed Form

Fax the fully completed Outpatient Medical Injectable Synagis Authorization Request Form and all required attachments to Highmark at 1-833-619-5745. If the form and supporting documentation are not received, the prior authorization request may be denied or processing delayed.

Fax number: 1-833-619-5745 (Medical Benefit Only)
Include: completed form, clinical attachments, referral, and prescription (if dispensing pharmacy will supply)
Consequence: incomplete submission or failure to fax required documentation may result in denial or delay

Definitions and Drug Reference

Synagis (palivizumab)

Drug name (brand)Synagis

Generic namePalivizumab

Billing/procedure codeCPT 90378 (SYNAGIS (palivizumab) injectable)

High-risk clinical categories (form-captured)

Born <29 weeks 0 daysInfant with preterm birth less than 29 weeks 0 days gestation

<32 weeks with CLDInfant with preterm birth less than 32 weeks 0 days with chronic lung disease (CLD)

Profoundly immunocompromisedInfant is profoundly immunocompromised during the RSV season

Hemodynamically significant CHDInfant with hemodynamically significant congenital heart disease

Cardiac transplantInfant is undergoing a cardiac transplant

Cystic fibrosis with CLD or nutritional compromiseInfant with Cystic Fibrosis with evidence of chronic lung disease (CLD) or nutritional compromise

Airway or neuromuscular disordersInfant born with congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions

OpenPayer

Outpatient Synagis (palivizumab) prior authorization request — coverage criteria and submission form

Coverage and Eligibility Criteria

Billing and Coding

Provider Actions and Submission Requirements

Definitions and Drug Reference

Background